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UW Medical Foundation (UWMF)
SAFETY POLICIES AND PROCEDURES
Subject: Hazardous Materials and Waste Management Plan
Effective Date: 3/14/16 Approved: Mike Holman, Safety Manager
Supersedes Policy Date: 7/22/13 Revision #4
To recognize the potential threat that hazardous materials and wastes
pose to human health and the environment. To establish, implement,
monitor and document evidence of an ongoing program for the
management of hazardous material and wastes. To ensure that there is
minimal risk to patients, personnel, visitors and the community
ξ Acid means any class of substances whose aqueous solutions are
characterized by sour taste, the ability to turn blue litmus red, the ability
to react with bases and certain metals to form salts and having pH of
less than 7.
ξ Caustic means a material that is able to burn, corrode, dissolve, or eat
away another substance.
ξ Combustible means having a flash point greater than 140F.
ξ Corrosive means a substance that causes visible destruction or
permanent change in human skin tissue at the site of contact. A liquid
that has a severe corrosion rate on steel.
ξ Dual waste contains both infectious and hazardous waste (i.e. left
over chemotherapy in a contaminated sharp device).
ξ Flammable means having a flash point less than 140F.
ξ Flash point means the lowest temperature at which a flammable
vapor-air mixture will ignite when an ignition source is introduced.
ξ Gaseous hazardous waste means any substance which may be
dispersed through the air and act as a poison, irritant or asphyxiate
(these include all full, partial or empty aerosolized cans).
ξ Hazardous material means a substance which by reason being
explosive, flammable, poisonous, corrosive, oxidizing, irritating or
otherwise harmful is likely to cause internal or external injury to
humans or the environment.
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ξ Incompatible is a term used to indicate that one material cannot be
mixed with another without the possibility of a dangerous reaction.
Flammables and combustibles
Corrosives and flammables
Oxidizers and flammables/combustibles
Acids and caustics
ξ Infectious waste means any material possessing a significant
potential for contagion or cross-infection.
ξ Oxidizer means a chemical that initiates or promotes combustion in
other materials, thereby causing fire either of itself or through the
release of oxygen or other gases.
ξ pH is a measure of how acidic or caustic a substance is on a scale
from 1 to 14 (1 = very acidic, 7 = neutral, 14 = very caustic).
ξ Radioactive hazardous waste means any material capable of giving
off radiant energy in the form of particles or rays such as alpha, beta
and gamma rays.
1. The Safety & Security Manager is responsible for the administering,
revising and evaluating of this plan.
2. Site Managers are responsible for the compliance of this plan and
coordinating the pickup and removal of unwanted hazardous materials
with the Safety & Security Manager.
3. Employees are responsible for following the safe practices as outlined
in plan and applicable Material Safety Data Sheets.
A. Hazardous Material Storage: All hazardous materials must be stored
in a manner that prevents the mixing of incompatibles or harmful
conditions or reactions. Staff will reference the storage
recommendations and reactivity sections on material safety data
sheets to ensure their hazardous material items are stored in a safe
manner. Generally, staff will follow the below safe practices:
Flammable materials will be stored in a cool, dry, well
ventilated space, away from areas of fire hazard and
separate from oxidizers.
Oxidizers will not be stored close to liquids of low
Acids will be stored in a cool, dry, well ventilated area,
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Corrosive materials will be stored in a cool, well
ventilated area (above their freezing point).
If child access is anticipated, hazardous material
items will be stored in such a manner as to prohibit
B. Generation of Unwanted Hazardous Materials:
i. Unwanted hazardous materials are generated at each facility on an
ongoing basis. These items may still have use in other UWMF
facilities. When a sufficient amount of this material is collected at
each location, the Safety & Security Manager transports them
according to Department of Transportation (DOT) hazardous
materials (HM) regulations to the UW Health Oregon Clinic. This
clinic is a satellite storage location for unwanted hazardous
ii. A hazardous waste determination will be performed by the Safety &
Security Manager for each item at the satellite storage location. If
the item cannot be reused, it is stored, labeled, and packaged
according to Resource Conservation and Recovery Act (RCRA)
and handled as hazardous waste by a UWMF licensed vendor and
transported, stored and disposed of in accordance with all
applicable state and federal regulations.
C. Management of Pharmaceutical Waste Policy: All pharmaceutical
waste must be disposed of in accordance with the procedures within
i. Expired, unopened vaccines and expensive items can be
returned to the Clinic Pharmaceuticals Purchasing Clerk.
a. Package the medication in a brown or white
unmarked bag and label with Location 101 Dept.
236. NOTE: Vials and ampules should be safely
packaged to prevent breakage. NEVER SEND
ii. All partially opened and unused flu vaccine vials must be
returned to the Clinic Pharmaceuticals Purchasing Clerk for
iii. Unwanted or excess medications may also be returned to Clinic
Pharmaceuticals Purchasing Clerk. Before returning, contact the
Purchasing Clerk. Credit will be issued for unopened,
reusable medications only.
a. If pharmacy is unable to accept a medication
return and/ or medication is not reusable, discard
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at the clinic (see Management of Unwanted
Hazardous Materials, section E).
iv. Expired, unopened UWMF controlled substances can be
returned to 1 S. Park Pharmacy (see Controlled Substances
Distribution Policy). Any opened or partially used controlled
substances can be wasted in the following manner:
a. Two staff must witness the wasting process. The
contents can be disposed of down the sanitary
sewer or toilet and documented on the Controlled
Substances Drug Disposition Record per the
Controlled Substances Distribution Policy.
v. UWMF Clinics cannot accept controlled substances or any
other medications from patients for disposal. Providers who
need confirmation previous controlled substance prescriptions
were destroyed before re-prescribing new can have patients
dispose of older prescription at UWMF and chart in Epic the
appropriate information (see below steps). With regard to all
other medications, Dane County patients can dispose of their
medications through the Dane County’s MedDrop Program (see
www.MedDropDane.org). Those residing outside of Dane
County should contact their municipality for disposal options.
a. Disposing of controlled substances – patient
must be in control of medication at all times.
Contents must be disposed of down the sanitary
sewer or toilet.
b. Two staff must witness the onsite disposal and
document the following in a Patient Safety Net
ξ Patient name and medical record number
ξ Record the medication and number of
ξ Two staff who has witnessed the disposal
vi. Hazardous pharmaceutical waste includes medications such as
epinephrine, nitroglycerin, warfarin, nicotine, antibiotics,
antidepressants, tranquilizers, blood lipid regulators and
“endocrine disruptors” such as estradiols, progesterones and
lindane (estrogen mimic). These waste medications must be
disposed of in accordance with section E of this policy. NOTE:
testosterone should be treated as a controlled substance.
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vii. All hazardous drugs must be disposed of in accordance with the
Hazardous Drug Waste Disposal Policy (see Hazardous Drug
Safety Program for comprehensive listing of hazardous drugs).
D. Management of Radioactive Waste Policy: Any radioactive waste
generated at UWMF sites will be disposed of at UW Hospital and
Clinics (UWHC) and under the direction of the UWHC Radiation Safety
E. Management of Unwanted Hazardous Materials:
i. Each material / chemical must be in the original packaging and
storage container or that of equal strength. All such items must
be labeled in accordance with the UWMF Labeling of Chemicals
ii. When staff determines that the hazardous material no longer
has a useful purpose at the site, the item will be relocated to a
secure area away from clean and sterile goods, food,
beverages, and patient traffic. These unwanted hazardous
materials will be separated and temporarily stored into pails
labeled with the following DOT classes (see examples in
iii. When a site has a sufficient amount of unwanted hazardous
materials, the site manager will coordinate a pick-up with the
Safety & Security Manager. This person will assess each item,
pack them in DOT transport containers, complete a Bill of
Lading and transport items to the satellite storage location.
NOTE: Unwanted hazardous materials at Meriter
Atrium, 1 & 20 S. Park can be temporarily stored at 1 S.
Park Facilities for pick up.
iv. The Safety & Security Manager will conduct periodic audits of
hazardous materials waste streams to ensure such items are
being disposed of properly and in accordance with state and
federal regulations. A listing of common healthcare wastes and
recommendations from the Wisconsin Department of Natural
Resources can be found in Attachment B.
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F. Management of Infectious Hazardous Waste (see Medical Waste
i. NOTE: if contaminated sharp devices contain more than trace
amounts of a hazardous pharmaceutical or drug, these must be
disposed of as dual waste. For these rare occurrences, place
contaminated sharp into a smaller sharps container and label as
“dual waste” and put with the other unwanted hazardous
materials for pickup by the Safety & Security Manager.
G. Management of Gaseous Hazardous Waste Policy: All full or partial
aerosolized containers must be disposed of in accordance with section
E (Hazardous Chemical Waste). Any full, partial or empty compressed
gas cylinders may be returned to the contracting vendor. Remember,
DO NOT VENT TO DISPOSE.
H. Management of Electronic Waste Policy: Any electronic waste must
be handled per the Recycling Policy. If an electronic item is not
specifically listed or addressed in the Recycling Policy, contact EHIC &
Safety for recommendations regarding proper disposal and/ or
I. Department of Transportation (DOT) Required Training: All
employees who are expected to sign manifests from an infectious and/
or hazardous waste hauler will complete the Hazmat Transportation
Security Awareness Training required by the DOT. This computer
based training will occur initially and annually thereafter. Employees
who have not taken the training cannot sign manifests and must defer
to those who have taken the training.
J. Resource Conservation and Recovery Act (RCRA) Required
Training: RCRA or hazardous waste training is required annually for
all employees and vendors handling, packaging or generating
hazardous waste. This training consists of knowledge of RCRA
regulations and generator requirements. It also involves hazard
communication in regard to each hazardous waste stream. A signed
certificate of training will be issued to each employee successfully
completing the required training. Success in completing the training will
involve exams or testing to ensure the employee has attained the
required skills necessary to do their job correctly.